Stroke
Marlou Abril, DO
New York Medical College/Metropolitan Hospital Center
Astoria, New York, United States
Ozan Soyer, MD
Resident Physician
New York Medical College / Metropolitan Hospital
Bronx, New York, United States
Jeremy Frank, MD
Resident Physician
NYMC/Metropolitan Hospital Center
New York, New York, United States
Marlou Abril, DO
New York Medical College/Metropolitan Hospital Center
Astoria, New York, United States
A 60-year-old male with hypertension was admitted to acute inpatient rehabilitation following a bilateral cerebrovascular accident. Initial examination revealed cachexia and depressed mood after a recent bereavement. The patient reported recent unintentional weight loss of 30 pounds, raising concern for an underlying malignancy. It was reported that the patient was scheduled to undergo a colonoscopy, but did not attend his appointment. On day 3, the patient became hypotensive and lethargic, triggering rapid response. Initial CT scan of the head and chest X-ray was unremarkable. Laboratory testing revealed a >2 g/dL drop in hemoglobin and an elevated blood urea nitrogen. The patient also had an episode of melena a few hours later. Internal medicine and Gastroenterology were urgently consulted, and the patient was transferred to the ICU for further management. Endoscopy the following day revealed gastric ulcers which were clipped. Following stabilization, the patient returned to acute inpatient rehabilitation.
Discussions:
This case highlights the importance of maintaining a broad differential diagnosis when a patient acutely deteriorates in the rehabilitation setting, beyond neurological causes. Although GI bleeds are rare in rehab, they are life-threatening and are associated with an increase in mortality and worse functional outcomes. This patient’s frailty, underlying psychosocial stressors, and concern for malignancy magnified his vulnerability. A successful outcome was achieved through rapid, coordinated collaborations between physiatry, internal medicine, gastroenterology, and critical care. This seamless multidisciplinary care improved the patient’s survival and minimized further disruption to his rehabilitation course.
Conclusions:
In conclusion, physiatrists must maintain a broad differential when assessing causes of sudden decline in stroke rehabilitation. Early recognition and rapid mobilization of a multidisciplinary team are essential in optimizing patient outcomes.
